I've already posted how some doctors have already made their personal mea culpa and come to the conclusion that for them they think single payer is better. Which is worse for doctors one gigantic government run system or myriads of private greedy business men controlling them?

I have made clear I don't want government controlling my life. But others in my profession have concluded otherwise. Many are my fellow Jewish doctors as this one here. They are all die hard Democrats. I must ask if they would feel so strongly about this if a Republican was promoting AHA. I doubt it. Some of my fellow Indian and Muslim and African colleagues also have expressed a desire for single payer. Doctors from the Eastern Europe theater tend to be disgusted with the shift to totalarism (sp?) exactly what they fled.

One must also keep in mind "correspondents" or whatever she is called like Snyderman make at least hundreds of thousands a year for the networks in these mouthpiece positions. Either way she is doing great. I wish I could get paid handsomely telling others to get in line with the State.

I can tell you this line is complete nonsense:

"Increase the bottom line for doctors so they don’t feel like they’re being nickeled and dimed with 10% less than Medicare, 5%... Docs just want to be reimbursed a fair amount for hard work."

I have never heard a doctor accuse Medicare of paying them a fair wage. In fact it is just the opposite. Insurers often follow Medicare reimbursement cuts. So this claim is ridiculous. Nonetheless some doctors have concluded that for their pocketbooks Medicare is the less of two evils. Personally I look at the broader picture beyond my pocketbook. I see the Government taking over our lives. Doctors, patients, all of us. To call signing up to Obamacare our patriotic duty is right out of the Communist Party playbook.

*****NBC’s Chief Medical Editor Forced Her Kids to Sign Up for Obamacare as Their ‘Patriotic Duty’

"So I made my kids sign up, because I just said this is your patriotic duty."

On Morning Joe Monday, NBC’s chief medical editor Dr. Nancy Snyderman, after arguing that the “biggest fix” for the American healthcare system would be single-payer, proudly declared that she had forced her own kids to sign up for Obamacare as their “patriotic duty.”

Snyderman was brought on to discuss a number of issues, but when hosts Harold Ford, Jr. and Wes Moore turned the discussion to Obamacare, Snyderman revealed just how far left her expert opinion leans, using the failures of the ACA as a means to push for a single-payer system.

Ford: As a physician, what’s the biggest fix that can be done to ensure that better care, affordable care gets to people that don't have it?

Snyderman: I think there should be a single-payer system. And, increasingly, you're seeing physicians in their late 50s, 60s, and 70s, who are saying, “You know what, we got it wrong. We should have taken Medicare, expanded it, and done it smarter. Increase the bottom line for doctors so they don’t feel like they’re being nickeled and dimed with 10% less than Medicare, 5%... Docs just want to be reimbursed a fair amount for hard work. This is making the terrain much, much, much, more difficult.

With Snyderman’s comments about Obamacare turning increasingly critical, Moore stepped in and tweaked the direction of the conversation to a more solution-based talking point:“Moore: You know what's interesting? So you talk about your kids and you talk about... one of the big challenges for Obamacare and the rollout so far has been how do we get the young and how do we get the healthy to sign up for healthcare? Which was a dynamic prior to Obamacare. How do we get the young and how do we get the healthy... That's the reason they came up with the plan.

Snyderman: So I made my kids sign up, because I just said this is your patriotic duty.

Israel has maintained a system of socialized health care since its establishment in 1948, although the National Health Insurance law was passed only on January 1, 1995. The state is responsible for providing health services to all residents of the country, who can register with one of the four health service funds.

...

Participation in a medical insurance plan with one of the four national HMOs is compulsory for all citizens, who can select and participate in any one of them regardless of factors such as age, gender, or pre-existing conditions.

Israel has maintained a system of socialized health care since its establishment in 1948, although the National Health Insurance law was passed only on January 1, 1995. The state is responsible for providing health services to all residents of the country, who can register with one of the four health service funds.

...

Participation in a medical insurance plan with one of the four national HMOs is compulsory for all citizens, who can select and participate in any one of them regardless of factors such as age, gender, or pre-existing conditions.

If there is something that I've learned over the years it's that you (think you) know more than experts.

I'll trust this guy:

NADAV MORAG is a faculty member at the Center for Homeland Defense and Security (CHDS), US Naval Postgraduate School. At CHDS he teaches courses on policy analysis and research methodology as well as a course entitled "Comparative Government for Homeland Security." He has authored articles on terrorism, strategy, and the Middle East, including "The Economic and Social Effects of Intensive Terrorism: Israel 2000-2004" (Middle East Review of International Affairs) and "Measuring Success in Coping with Terrorism: The Israeli Case" (Studies in Conflict and Terrorism). He previously served as a senior director at Israel's National Security Council where he was responsible for developing policy recommendations in areas of national security for the prime minister and the cabinet.

I see that law enforcement is covered in chapter 4. I don't see government healthcare-generational theft schemes listed. And, no public health isn't included in that. Stopping pandemics/bioweapons is different than mandating the public buy insurance that covers gender reassignment surgery.

One thing I've noticed about you is that you are all too willing to grovel before anyone you think has the proper credentials. It's what academia does, I know. Unfortunately all that time in the ivory tower prevents one from tangible real world experience, which might allow one to discern bullshit, even when it's wrapped in an academically compliant or MSM shiny package.

"I see that law enforcement is covered in chapter 4. I don't see government healthcare-generational theft schemes listed. And, no public health isn't included in that. Stopping pandemics/bioweapons is different than mandating the public buy insurance that covers gender reassignment surgery."

You are quite right: law enforcement is covered. But there is, in fact, so much more that law enforcement covered in the book. Israel includes public health in its responses to homeland security threats.

"One thing I've noticed about you is that you are all too willing to grovel before anyone you think has the proper credentials. It's what academia does, I know. Unfortunately all that time in the ivory tower prevents one from tangible real world experience, which might allow one to discern bullshit, even when it's wrapped in an academically compliant or MSM shiny package."

I actually came back to edit the beginning of my previous post. I was frustrated about something else. Too late for that, but thanks for making my point for me. You are probably right. I can't imagine how some who "previously served as a senior director at Israel's National Security Council where he was responsible for developing policy recommendations in areas of national security for the prime minister and the cabinet" might have proper credentials to know a damn thing about Israeli homeland security.

Supporters of President Obama’s health care law had predicted that expanding insurance coverage for the poor would reduce costly emergency room visits because people would go to primary care doctors instead. But a rigorous new experiment in Oregon has raised questions about that assumption, finding that newly insured people actually went to the emergency room a good deal more often.

The study, published in the journal Science, compared thousands of low-income people in the Portland area who were randomly selected in a 2008 lottery to get Medicaid coverage with people who entered the lottery but remained uninsured. Those who gained coverage made 40 percent more visits to the emergency room than their uninsured counterparts during their first 18 months with insurance.

The pattern was so strong that it held true across most demographic groups, times of day and types of visits, including those for conditions that were treatable in primary care settings.

The findings cast doubt on the hope that expanded insurance coverage will help rein in emergency room costs just as more than two million people are gaining coverage under the Affordable Care Act. And they go against one of the central arguments of the law’s supporters, that extending insurance to large numbers of Americans would reduce emergency room use, and eventually save money.

In remarks in New Mexico in 2009, Mr. Obama said: “I think that it’s very important that we provide coverage for all people because if everybody’s got coverage, then they’re not going to the emergency room for treatment.”

The study suggests that the surge in the numbers of insured people may put even greater pressure on emergency rooms, at least in the short term. Nearly 25 million uninsured Americans could gain coverage under the law, about half of them through Medicaid. The first policies took effect on Wednesday.

“I suspect that the finding will be surprising to many in the policy debate,” said Katherine Baicker, an economist at Harvard University’s School of Public Health and one of the authors of the study.

An administration spokeswoman, Tara McGuinness, said that the time frame was too short to expect much of a change, and that over the longer term, use would most likely decline. She pointed to a longer-term study in Massachusetts, which expanded coverage for its residents in 2006, that found an 8 percent decline in emergency department use over a period of several years.

But many economists say that the emphasis on emergency room use, both in policy and in political speeches, is misplaced, as it makes up only a small part of health care costs in the United States. A federal government health survey found that emergency departments accounted for about 4 percent of total health spending in 2010, far less than inpatient hospital visits, which accounted for about 31 percent. Certain populations, however, like low-income people with chronic illnesses, have much higher rates of use.

Dr. Baicker and Amy Finkelstein, an economist at the Massachusetts Institute of Technology, another author, said the increased use of emergency rooms is driven by a basic economic principle: When services get less expensive, people use them more. Previous studies have found that uninsured people face substantial out-of-pocket costs that can put them in debt when they go to the emergency room. Medicaid reduces those costs.

Medicaid coverage also reduces the costs of going to a primary care doctor, and a previous analysis of data from the Oregon experiment found that such visits also increased substantially.

“This is just one piece of an increase we found across every type of care,” said Bill J. Wright, an author of the new study who is the associate director of the Center for Outcomes Research and Education in Portland, a part of Providence Health and Services, a large health care provider.

The study’s authors emphasized that Medicaid had many benefits. Previous analyses from the experiment found that gaining coverage reduced the incidence of depression and increased feelings of financial stability.

The study drew on data from the Oregon Health Insurance Experiment that included about 90,000 low-income Oregonians and randomly assigned about 30,000 of them access to Medicaid. Health experts say the experiment’s design — random assignment of coverage through a lottery — allowed them to isolate and evaluate the effects of the program. Such designs are the gold standard in medical research, but are rarely used for domestic health care policy.

****"One thing I've noticed about you is that you are all too willing to grovel before anyone you think has the proper credentials. It's what academia does, I know. Unfortunately all that time in the ivory tower prevents one from tangible real world experience, which might allow one to discern bullshit, even when it's wrapped in an academically compliant or MSM shiny package."

I actually came back to edit the beginning of my previous post. I was frustrated about something else. Too late for that, but thanks for making my point for me. You are probably right. I can't imagine how some who "previously served as a senior director at Israel's National Security Council where he was responsible for developing policy recommendations in areas of national security for the prime minister and the cabinet" might have proper credentials to know a damn thing about Israeli homeland security.****

From the education thread is my proposal to beware the academic industrial government complex.

OF course there is much to learn from our scientific community. But much harm can come from it too.

We are seeing an infinite exponential rise in "studies" and experiments the vast majority of which are total BS. We see it in the health field ALL the time. If one or two percent of all the research done actually gives us new meaningful information that changes the way we practice medicine that is a lot.

Indeed look at how many times over the last decade we in the medical community have kept changing our recommendations.

For example I just read online that Vit E supposedly helps delay Alzheimer's ( a tad by maybe six months - at best). In the nineties this was claimed too until additional tests suggested it might worsen or not help. So which the "f" is it? I would not recommend anyone waste their money on high doses of Vit E (2,000 IU per day).

I guarantee one thing. We will hear over the radio, the cable, the online airwaves many shysters selling us their Vit E promoting with this study as the evidence that it is real.

I do question whether these professors have already cut deals with the promoters of these products to cash in. They are supposed to report "conflict of interests". Don't count on it. And don't think for one second this doesn't happen either.

There are many great men and women in academia. But there are just as many scum bags as every other sector of society. So GM is absolutely correct in taking academic's claims with some skepticism.

The spread of controlled trials into economics is just another example of the tumbleweed spreading of "science". Also I have shown in posts years past how anyone can often juggle the data to suggest any outcome best for their cause.

http://en.wikipedia.org/wiki/Health_care_in_IsraelFrom the entry:Israel has maintained a system of socialized health care since its establishment in 1948, although the National Health Insurance law was passed only on January 1, 1995. The state is responsible for providing health services to all residents of the country, who can register with one of the four health service funds....Participation in a medical insurance plan with one of the four national HMOs is compulsory for all citizens, who can select and participate in any one of them regardless of factors such as age, gender, or pre-existing conditions.

I think the importance of this post was missed and deserves addressing. I was confused by the title and others went off on other tangents. If I am not mistaken, Bigdog is asking, if this works in Israel, why not here?

http://en.wikipedia.org/wiki/Health_care_in_IsraelFrom the entry:Israel has maintained a system of socialized health care since its establishment in 1948, although the National Health Insurance law was passed only on January 1, 1995. The state is responsible for providing health services to all residents of the country, who can register with one of the four health service funds....Participation in a medical insurance plan with one of the four national HMOs is compulsory for all citizens, who can select and participate in any one of them regardless of factors such as age, gender, or pre-existing conditions.

I think the importance of this post was missed and deserves addressing. I was confused by the title and others went off on other tangents. If I am not mistaken, Bigdog is asking, if this works in Israel, why not here?

When so many Americans are paying much higher prices for health insurance under Obamacare and others can’t even afford to buy coverage, it is wrong for our money to be used to bail out giant insurance companies. But as Charles Krauthammer points out in his recent column, an insurance company bailout is already written into the law, just waiting to kick in if the best-laid plans of the politicians and the bureaucrats go awry.

To keep their costs (and our premiums) under control, insurance plans need about 4 in 10 of those who enroll to be young and relatively healthy -- the type of people who might be less inclined to buy insurance in the first place. If the rate of young people signing up for coverage is much lower than that, insurers will be in a financial bind, paying the expensive medical bills of older Americans without more profitable young customers to balance out the cost.

Normally that would force the insurance companies to raise their premiums to cover the shortfall. President Obama, however, knew that a process of rising prices and declining healthy enrollees would destroy Obamacare. They needed a solution that would hide the true costs. That solution was a taxpayer bailout for insurance companies.

To compensate the insurance companies for the risk of signing on to Obamacare, the law's designers slipped in a massive bailout provision: if the companies’ costs turned out to be higher than they “anticipated,” the federal government can cover as much as 80 percent of their losses.

This is a system that encourages the insurance companies to be unrealistic about their risks because you the taxpayer are set up to cover their mistakes.

After months of failing exchanges, there’s good reason to believe that the customers who endured the frustration of online enrollment are the ones who need health coverage the most--in other words, the most expensive customers. Compounding the problem, the Obama administration has been modifying the law by presidential pronouncement, largely in ways that will diminish the number of young and healthy people enrolling. As Krauthammer describes in his column: First, it postponed the employer mandate. Then it exempted from the individual mandate people whose policies were canceled (by Obamacare). And for those who did join the exchanges, Health and Human Services Secretary Kathleen Sebelius is “strongly encouraging” insurers — during the “transition” — to cover doctors and drugs not included in their clients’ plans.

The insurers were stunned. Told to give free coverage. Deprived of their best customers. Forced to offer stripped-down “catastrophic” plans to people age 30 and over (contrary to the law). These dictates, complained an insurance industry spokesman, could “destabilize” the insurance market. These modifications threaten to make the insurance plans on the Obamacare exchanges financially unsustainable, which would put the taxpayers on the hook for an expensive--in fact, virtually unlimited--bailout of the insurance companies.

I call on Congress to block any bailout for big insurance companies under Obamacare by repealing sections 1341 and 1342 of the Affordable Care Act. When Americans have to pay more for insurance and many cannot even buy insurance it is totally wrong for our money to be used to bail out giant insurance companies.

I will let my friends know that they should sign this petition also.

No taxpayer bailout for insurance companies.Sign the Petition Now Your Friend,Newt

While a lot of conversation is percolating about ObamaCare being the gateway to a single-payer health care system such as those strangling Canada and the United Kingdom, there's another financial concern for the interim and it involves those insurance companies allowed to participate in the various federal and state exchanges. Few can escape the fact that health plans now feature higher premiums and deductibles than the ones we were supposed to be able to keep if we liked them. Since there's such a disincentive to purchase, Democrats had to ensure that insurance companies would survive. That requires the right incentives and enough taxpayer money to make it worth their while.

Charles Krauthammer shrewdly points out in a recent column that Sections 1341 and 1342 of the Patient Protection and Affordable Care Act provide a means for the federal government to bail out insurers who are seeing the coveted youth market decide to forgo coverage while those who can afford the coverage thanks to massive federal subsidies tend to be older and sicker. In a normal market, this would be a recipe for failure.

But Section 1341, writes Krauthammer, provides for a $20 billion "reinsurance" fund over the next three years while Section 1342 allows insurers who have costs as little as 8% over a predetermined "target" amount to recoup 80% of these excesses. As Newt Gingrich notes, "This is a system that encourages the insurance companies to be unrealistic about their risks because you the taxpayer are set up to cover their mistakes."

As Krauthammer sees it, the solution would be to excise both these bailouts from ObamaCare, either as a standalone measure or as an amendment to the upcoming debt ceiling bill. In the current political climate, though, the question is whether GOP leadership would carry through with such a fight.

Ezra Klein is a liberal commentator, is correcting liberals here, and has a liberal idea of where healthcare should go. Opinions and solutions aside, I think he does a pretty good job here getting at key facts on health care systems and participants.

Documentarian Michael Moore greeted the introduction of Obamacare with an admission many liberals will cheer. “Obamacare is awful,” he wrote.

Its awfulness, Moore said, stems from “one fatal flaw: The Affordable Care Act is a pro-insurance-industry plan implemented by a president who knew in his heart that a single-payer, Medicare-for-all model was the true way to go.”

Like Moore, I’d prefer a more nationalized health-care system. But his analysis relies on a common mistake that distorts both the benefits of single-payer systems and the deficiencies peculiar to Obamacare.

Insurers are the bogeymen of American health care. That’s in part because they do a lot of the unpopular stuff: They’re the ones who charge you money for health care, who say you can’t get something you want, who your bosses blame when they deduct more money from your paycheck to cover health costs. And it’s hard to see what value they add to the system.

Yet the problem with the Affordable Care Act isn’t the insurance industry. In fact, the main benefits of nationalized health care can be achieved in systems with hundreds, even thousands, of for-profit insurers.

Insurers aren’t even where the big money goes. In 2009, Forbes ranked health insurance as the 35th most profitable industry, with an anemic 2.2 percent return on revenue. To understand why the U.S. health-care system is so expensive, you need to travel higher up the Forbes list. The pharmaceutical industry was in third place, with a 19.9 percent return, and the medical products and equipment industry was right behind it, with a 16.3 percent return. Meanwhile, doctors are more likely than members of any other profession to have incomes in the top 1 percent.

In general, Americans don’t use more health care than citizens of other countries. But we pay a lot more for the health care we do get. Data gathered by the International Federation of Health Plans show that an MRI costs, on average, $1,121 in the U.S. and $363 in France. An appendectomy costs $13,851 in the U.S. and $4,782 in Switzerland. A birth by cesarean section costs $3,676 in the U.S. and $606 in Canada. A bottle of Nexium -- a common acid-reflux drug -- costs $202 in the U.S. and $32 in the U.K.

The dirty truth about American health care is that it costs more not because insurers are so powerful, but because they’re so weak.

There are few truly single-payer systems in the developed world. Canada has one, as does Taiwan. Most countries rely on many, many insurers. Germany, for instance, has more than 150 “sickness funds.” The Swiss and Dutch health systems look a lot like Obamacare’s health-insurance exchanges. In France, about 90 percent of citizens have supplementary health insurance. Sweden has moved from a single-payer system to one with private insurers. Yet all these countries pay vastly less for drugs, surgeries or doctor visits than Americans do.

Why? Because in every case the government sets prices for health-care services and products. Insurers in Switzerland don’t negotiate drug prizes with Pfizer. The Swiss government simply sets its drug prices and lets Pfizer decide whether to sell in Switzerland -- or not.

“The problem is that in the U.S. payers are fragmented while in other countries they are unified even if there are many insurers,” said Gerard Anderson, director of the Center for Hospital Finance and Management at Johns Hopkins University.

In the U.S., insurers negotiate with hospitals and drug companies on their own -- and they pay more as a result. In fact, because of their weak negotiating position they frequently use whatever price Medicare is paying as a baseline and then, because they lack the power to strike a similar deal, add a percentage on top. Joshua Gottlieb, an economist at the University of British Columbia, found that when Medicare increases what it pays for a service by $1, private insurers increase their payments by $1.30.

That leaves the U.S. with the worst of both approaches: Prices aren’t set by the market, but they also aren’t set by the government. Consequently, Medicare’s negotiating power is weakened by the threat that drug companies or hospitals will opt to do business only with higher-paying private insurers. We simultaneously miss out on the efficiency of a purely private system and on the savings of a purely public one.

If insurers lose on negotiating with medical providers, however, they’re much better than the government at innovating on insurance design. Co-pays and deductibles aren’t popular, but they work. Many insurers are experimenting with ways to create incentives for better health, including using personal technology -- everything from e-mails to smartphone cameras. (The disastrous introduction of the Obama administration’s HealthCare.gov website hardly instills confidence in the government’s capacity to exploit digital medicine with similar efficiency.)

“Single payer isn’t a panacea,” said Uwe Reinhardt, a health economist at Princeton University. “The magic they have is setting rates. But neither Medicare nor Canada has done anything innovative on the delivery side. Taiwan is trying a little bit but not a whole lot. By and large they just pay bills.” The limitations of single-payer systems became clear during the health-care debate, when the Congressional Budget Office projected that premiums for a public option would be higher than premiums for private insurance -- unless a public option could avail itself of Medicare’s pricing power.

A health-care system that followed international best practices would direct the government to set rates. Or it would let insurers band together and negotiate rates collectively -- a practice called “all-payer rate setting.” But it wouldn’t need to eliminate private insurers. It’s good for consumers to have a choice of insurers, who have real incentives to innovate and devise better ways to keep customers healthy and costs down.

It’s health-care providers -- not insurers -- who have too much power in the U.S. system. As a result, they have the most to lose if health-care prices fall. But, as is often the case, political power flows in part from popularity. So politicians who routinely rail against for-profit insurers are scared to criticize -- much less legislate against -- for-profit hospitals, doctors or device manufacturers (though drug companies come in for a drubbing now and then). These are the people who work every day to save our lives, even if they make us pay dearly for the privilege.

Obamacare, also known as Generational Theft 2.0, is advertising aggressively to young people. It's hip, it's cool to go to the exchanges and get covered. It is also kind of a silly (and wasteful) exercise to advertise that which will shortly be mandated. We need young, healthy people who won't use the services to sign up and pay to cover old sick people who will sign up and use/over-use the services.

Real ads to sell things have prices in the ads: iphones, cars, tires, furnaces. Healthcare coverage is just hip, and easy! Just a click or two and give away every personal piece of information you have away from new coverage.

So how is the government healthcare ad campaign to young people going?

Besides the disappointing total number of people signing up, less than a quarter of them are young people when the targeted percentage was 40%. With its first public disclosure of Obamacare demographic data, the Department of Health and Human Services said that of the 2.2 million who enrolled in new health plans through federal and state exchanges by Dec. 28, just 24 percent were between the ages of 18 and 34. …

The White House, however, originally estimated that 2.7 million of a projected 7 million people — or nearly 40 percent — enrolling in Obamacare by the end of March would be from the youngest demographic.

79% of all signups are eligible for subsidies. The small minority who do not receive subsidies (21%) are obviously not enough to pay the freight for the 79% who get government money, so it is hard to see how Obamacare can ever add up as a sustainable program. Unless the administration assumes that it will be an endless drain on the federal budget.http://www.powerlineblog.com/archives/2014/01/obamacare-numbers-arent-adding-up.php

Former Marine Corps cyberwarfare expert David Kennedy has been testing Healthcare.gov for some time, warning all along about its security vulnerabilities. Now that the administration has "fixed it," however, he says the site is "much worse off" than ever. As for no successful hacks to date, Kennedy warns, "They haven't detected any attacks on the website, because they don't have the capability to detect them." That's bad, but it gets worse. He says you don't even really have to "hack" the website because it's more akin to leaving your car doors wide open: "You can literally just open up your browser, go to this [query] and extract all this information." If you like your security, you can keep it.

The Chart That Could Sink Obamacare Chris ConoverChris Conover Contributor

Except the Coburn-Burr-Hatch plan (read it here) amounts, among other things, to a big tax increase. The main way that it remains budget neutral is by making employer-provided health insurance plans, which are currently not taxed, partially taxable as income. In fact, this income replaces income that, under ObamaCare, comes from taxing companies, including the tax on medical device companies paid by firms like Medtronic and Stryker .

This fact has not escaped the notice of some prominent health reform allies. “It is a huge tax increase on workers without any confidence that they will be able to afford health insurance in the future,” says Bob Kocher, a partner at venture capital firm Venrock who previously worked in the Obama administration.

It is “essentially a very large Republican tax increase,” says Ezekiel Emanuel, the Diane V.S. Levy and Robert M. Levy University Professor of Medical Ethics and Health Policy at the University of Pennsylvania and another former Obama advisor. “It’s quite clear the plan is to put a bigger burden on middle class Americans.”

Here’s what the Senators propose: right now, health insurance is not taxed as income. This is arguably the original sin of the U.S. healthcare system, which has insulated consumers from health costs and allowed prices to skyrocket. During World War II, wages were frozen but pensions and benefits were exempted; in 1943 the Internal Revenue Service ruled that these benefits weren’t taxable, either.

Many health economists believe this is a bad thing, because it shields people from paying their own premiums, and Coburn, Burr, and Hatch deserve credit for tackling this head on. But that doesn’t make this any more politically workable – or appealing to those of us who get health insurance through our employers.

They write:

“Therefore, our proposal caps the tax exclusion for employee’s health coverage at 65 percent of an average plan’s costs. The value of employer-sponsored health insurance would be capped and indexed to grow at an annual rate of CPI +1.

Taxing 35% of the average plan – and more than that for plans that are above-average, as half are, could amount to a substantial tax. Tying the growth of the tax-exempt portion of the plan to the Consumer Price Index would also limit the cost of plans, pushing cost-saving measures.

How big a tax might this be for an average American family? Ezekiel has some numbers. The average employer health plan for a family of four costs $16,351, according to the Kaiser Family Foundation, and the employer covers 72% of that, or $11,772. Thirty-five percent of $11,772 is $4,120.35. The employee’s share of the Social Security and Medicare payroll tax is 7.65%, or $315.21. Assuming this family of four is in the 25% marginal income tax bracket, that would add another $1,030.09, for a total tax increase of $1,345. (For more from Emanuel, see this Times piece.)

Up to 300% of the poverty line, there would be subsidies to help people buy insurance. It’s not immediately clear how these compare to the subsidies offered by Obamacare; they don’t look greater.

Removing a bunch of corporate taxes so that the middle class can pay more seems like a political non-starter, even given the public backlash against Obamacare. This plan would likely mean that more people would lose insurance, or be forced to go to smaller networks of doctors. Those are the same criticisms levied against the Affordable Care Act.

Another notable thing about the proposal is how much of the ACA it keeps: it gets rid of state healthcare exchanges, but it keeps the basic structure of trying to keep people in the insurance system (in this case by making pre-existing conditions something that insurers can’t use against you until you fail to sign up for coverage – and then you get slammed) and of paying subsidies to help poor people get insurance. Allowing less comprehensive benefits and allowing insurers to charge five times as much for their sickest and oldest customers as for their youngest and healthiest, compared to three times under Obamacare, could lower the cost of insurance for young people and get more of them in the system.

“The plan makes specific proposals worthy of serious consideration- although I doubt it receives it at this moment,” says Ronald Williams, the former chairman of Aetna. “Perhaps in the future it could be the foundation of serious conversations which could lead to bipartisan evolution of the current bill.”

What the plan does emphasize is the degree to which any plan to reform the insurance system can seem like a zero-sum game – the money has to come from somewhere. For insurers involved in the ObamaCare exchanges, like Humana, Molina Healthcare, and Centene, the legislative roller-coaster ride may be far from over.

By George F. Will, Published: January 29 Someone you probably are not familiar with has filed a suit you probably have not heard about concerning a four-word phrase you should know about. The suit could blow to smithereens something everyone has heard altogether too much about, the Patient Protection and Affordable Care Act (hereafter, ACA).

Scott Pruitt and some kindred spirits might accelerate the ACA’s collapse by blocking another of the Obama administration’s lawless uses of the Internal Revenue Service. Pruitt was elected Oklahoma’s attorney general by promising to defend states’ prerogatives against federal encroachment, and today he and some properly litigious people elsewhere are defending a state prerogative that the ACA explicitly created. If they succeed, the ACA’s disintegration will accelerate.

Because under the ACA, insurance companies cannot refuse coverage because of an individual’s preexisting condition. Because many people might therefore wait to purchase insurance after they become sick, the ACA requires a mandate to compel people to buy insurance. And because many people cannot afford the insurance that satisfies the ACA’s criteria, the ACA mandate makes it necessary to provide subsidies for those people.

The four words that threaten disaster for the ACA say the subsidies shall be available to persons who purchase health insurance in an exchange “established by the state.” But 34 states have chosen not to establish exchanges.

So the IRS, which is charged with enforcing the ACA, has ridden to the rescue of Barack Obama’s pride and joy. Taking time off from writing regulations to restrict the political speech of Obama’s critics, the IRS has said, with its breezy indifference to legality, that subsidies shall also be dispensed to those who purchase insurance through federal exchanges the government has established in those 34 states. Pruitt is challenging the IRS in the U.S. District Court for the Eastern District of Oklahoma, and there are similar challenges in Indiana, Virginia and Washington, D.C.

The IRS says its “interpretation” — it actually is a revision — of the law is “consistent with,” and justified by, the “structure of” the ACA. The IRS means that without its rule, the ACA would be unworkable and that Congress could not have meant to allow this. The ACA’s legislative history, however, demonstrates that Congress clearly — and, one might say, with malice aforethought — wanted subsidies available only through state exchanges.

Some have suggested that the language limiting subsidies to state-run exchanges is a drafting error. Well.

Some of the ACA’s myriad defects do reflect its slapdash enactment, which presaged its chaotic implementation. But the four potentially lethal words were carefully considered and express Congress’s intent.

Congress made subsidies available only through state exchanges as a means of coercing states into setting up exchanges.

In Senate Finance Committee deliberations on the ACA, Chairman Max Baucus (D-Mont.), one of the bill’s primary authors, suggested conditioning tax credits on state compliance because only by doing so could the federal government induce state cooperation with the ACA. Then the law’s insurance requirements could be imposed on states without running afoul of constitutional law precedents that prevent the federal government from commandeering state governments. The pertinent language originated in the committee and was clarified in the Senate. (See “Taxation Without Representation: The Illegal IRS Rule To Expand Tax Credits Under The PPACA,” by Jonathan H. Adler and Michael F. Cannon in Health Matrix: Journal of Law-Medicine.)

Also, passage of the ACA required the vote of every Democratic senator. One, Nebraska’s Ben Nelson, admirably opposed a federal exchange lest this become a steppingstone toward a single-payer system.

If courts, perhaps ultimately including the Supreme Court, disallow the IRS’s “interpretation” of the law, the ACA will not function as intended in 34 states with 65 percent of the nation’s population. If courts allow the IRS’s demarche, they will validate this:

By dispensing subsidies through federal exchanges, the IRS will spend tax revenues without congressional authorization. And by enforcing the employer mandate in states that have only federal exchanges, it will collect taxes — remember, Chief Justice John Roberts saved the ACA by declaring that the penalty enforcing the mandate is really just a tax on the act of not purchasing insurance — without congressional authorization.

If the IRS can do neither, it cannot impose penalties on employers who fail to offer ACA-approved insurance to employees.

If the IRS can do both, Congress can disband because it has become peripheral to American governance.

****Why Does Health Care Cost so Much in America? Ask Harvard’s David Cutler

BY Paul Solman November 19, 2013 at 5:23 PM EST

By David Cutler

The American health care system is structured differently from systems in other countries, making it more expensive. Photo courtesy of Joe Raedle/Getty Images.

Paul Solman: Harvard’s David Cutler is among the country’s foremost health economists, famous for — among other research — a controversial paper arguing that even our exorbitant health care industry, in terms of increased productivity and life span outcomes, delivers more than what we pay for it.

Cutler, who was profiled by Roger Lowenstein in the New York Times Magazine in 2005, subsequently worked for President Barack Obama on health care issues, and talked to us recently for a story about cost savings. But far more of what he had to say seemed worthwhile than what we have time to air. Here is some of it.

Paul Solman: Why does health care cost so much in America?

David Cutler: Let me give you three reasons why. The first one is because the administrative costs of running our health care system are astronomical. About one quarter of health care cost is associated with administration, which is far higher than in any other country.

Paul Solman: What’s the next highest?

MORE FROM THE BUSINESS DESK:

Harvard’s David Cutler on How to Cut Health Care Costs

David Cutler: About 10, 15 percent. Just to give you one example, Duke University Hospital has 900 hospital beds and 1,300 billing clerks. The typical Canadian hospital has a handful of billing clerks. Single-payer systems have fewer administrative needs. That’s not to say they’re better, but that’s just on one dimension that they clearly cost less. What a lot of those people are doing in America is they are figuring out how to bill different insurers for different systems, figuring out how to collect money from people, all of that sort of stuff.

The second reason health care costs so much in America is that the U.S. spends more than other countries do on many of the same things. Drugs are the most commonly noted item, where a branded drug will cost much more in the U.S. than in other countries. But, for example, doctors also earn more for doing the same thing in the U.S. than they do in other countries, and a lot of suppliers charge more for things like durable medical equipment in the U.S. than in other countries.

Paul Solman: And that’s not only doctors being paid more in this country, but the United States making the decision as a government not to buy drugs in bulk and therefore to bid down the price that pharmaceutical companies can charge.

David Cutler: The lowest prices for pharmaceuticals, and a variety of other medical devices and payments to physicians, are in government plans. So Medicaid gets the best prices on pharmaceuticals. In terms of physician payments, Medicaid payments are the lowest. Medicare payments are above that and private payments are above that. The more leverage the buyer has, the lower the price they get. That’s true in every industry. In health care, the United States doesn’t utilize that leverage as much as other countries do.

Paul Solman: Okay, so that’s two and what’s the third reason?

David Cutler: The third one is Americans receive more medical care than people do in other countries, not so much in terms of doctor visits, but if a person has a heart attack in the United States, they’re much more likely to get open heart surgery than they are in most other countries.

Go back to Canada. In all of Ontario there are 11 hospitals that can do open heart surgery. Pennsylvania has roughly the population of Ontario and it has a bit over 60 hospitals that can do open heart surgery. So there’s no way you can operate on as many people in Ontario as you can in Pennsylvania even if you operated around the clock.

Paul Solman: But that means that the people in Canada or in Ontario have to wait longer right?

David Cutler: Sometimes they wait longer. What’s much more common is that there’s a lot of gray area where it’s not clear if you need the open heart surgery or not, and in the U.S., people will get it and in Canada, they don’t. The interesting thing about it is that life expectancy or one-year mortality after a heart attack is the same in the two countries.

Is The Rise of Costs Inevitable?

Paul Solman: Are medical costs going to inevitably go up because there will always be new technologies and new technologies are always expensive?

David Cutler: Technology is the underlying driver and there will always be some of that, which is why health care will not be like other industries in terms of always, always going down in price.

On the other hand, there’s so much waste in the system — our best guess is that about a third of medical spending is not associated with improved outcomes — that for the next 15 to 20 years people believe that costs could be stable or falling as a share of the economy without cutting into necessary services — just by eliminating the things that are not necessary…

What we’ve done in Massachusetts is we’ve said, don’t just give people very high cost-sharing in general; do what’s called tiering it — that is, tell people that if you look for basic levels of care, you’re not going to face very high costs, but if you want to go to the teaching hospital for the routine procedure, you’re going to have to pay a lot for that. And we mandate that insurance companies have to tell people the price of any service. So if your doctor says you need an MRI, you can go on the computer and your insurance company’s website and figure out exactly your cost sharing at each place where they would do the MRI.

Paul Solman: So that will provide comparison shopping.

David Cutler: That’s on the demand side. Give people more skin in the game and give them the information so they can do real shopping.

Paul Solman: More skin in the game, meaning higher co-pays?

David Cutler: Higher co-pays. We know that people respond to co-payments and they like cheaper care. So the hope is to steer people to less expensive sites. We’ve also pushed very strongly that insurance payments to doctors and hospitals and other care providers not be based on volume (so-called “fee for service”), but instead be value-based payments.

So say, here’s a person with coronary artery disease. Pay a fixed amount for that person and let the medical professionals figure out how to treat that person, not with the incentive to do more and earn more, but with the incentive to figure out how to do what’s right and keep them from using very expensive services.

Paul Solman: But doesn’t that provide an incentive or a prod to the provider to stint on the services, stint on the MRI, say, that I might otherwise get?

David Cutler: What that’s being coupled with is a very aggressive approach to measuring quality. … Really what we’re doing is two things: one is on the demand side trying to make people smarter consumers, and the second is on the provider side, eliminating the monetary incentives to do more testing and procedures. Instead, let’s move to a system that says, “do what’s appropriate, make the patients better and you’ll get rewarded for it.”

What If I Want a Certain Procedure?

Paul Solman: Well it sounds ideal, but I just keep thinking that I’d want to go to the dermatologist every six months, say, just to check out every possible discoloration. I’m a little crazy that way, but also, I feel, maximally prudent.

David Cutler: A lot of provider organizations are putting the doctors on a salary basis. Let’s gather our doctors together to figure out what the evidence says is right. If the literature is clear, let’s make sure we do that 100 percent of the time. If the literature is not clear, let’s go through our records and see how we can do better. If the patient then wants more, then say, “Okay, fine, you can have that, but you’re going to pay a little more because that’s not what the literature says is necessary in your case.”

Paul Solman: Well, of course, presumably my insurance company is already trying to do that.

David Cutler: Typically they’re very bad at it though, and when they tell the doctors they’ve imposed this, it goes poorly.

Paul Solman: So right now, I go to a dermatologist on a regular basis — I’ve always had some skin difficulties, but I’ve never had a melanoma — and that’s covered by my insurance. You’re saying, hey, if I’m a little paranoid with regard to discolorations, fine, let me go, but then I ought to pay to do that?

David Cutler: Increasingly, I believe insurers will make you pay more for care that you want to do that’s not medically necessary.

Paul Solman: Well medically necessary by what standards?

David Cutler: Care that’s ordered; that’s not following some accepted standard. You see this in certain parts of the country where the insurers say, “We’ll pay only a fixed amount for a knee replacement. We’ve determined that high quality knee replacement can be had for $8,000 nearby you. So we’ll give you $8,000. Now if you want to go to someone else who charges $20,000, fine, but you’re gonna pay the extra $12,000.”

Paul Solman: And my insurer did that recently with regard to a bronchial inhaler and said, “No, you can’t get that one; you can only get this cheaper one.”

David Cutler: Exactly, it’s what they’ve been doing with drugs for quite a long time. The generic version is very cheap; the branded drug is much more expensive.

In a lot of parts of the country, they’re just saying, “Look, if you want this service at all, you’re going to pay a lot of money.” The trend in health care nationally is to put more and more on the patient.****

This is interesting as I had patients coming in reporting they did not want drugs I prescribed because they were too expensive. I was shocked since these were drugs that should have been quite inexpensive.

From Crafty's link: "The average cost of a hip replacement in the US is $40,364." "The same operation in Spain costs an average of $7371."

"I don't have a good concise answer for that , , , and if I can't be concise, do I really understand?"

There are two aspects to this: Why is healthcare here so expensive, and a specific example is cited of the same procedure performed in two different places.

If the price difference is more than a plane ticket, and the quality, availability, reliability etc. are identical, why would people not just go there? http://www.nytimes.com/2013/08/04/health/for-medical-tourists-simple-math.html?_r=0

Prices are not coming down because there is no competitive market to drive them down, before or after Obamacare.

From the NY Time piece: "hospital charges (for hip replacement) run $65,000, not including the surgeon’s fee".

If you asked the surgeon what exactly he needs in a hospital room to perform a hip replacement, I don't see how it comes to $65,000. The surgical time for a hip replacement is 25 to 30 minutes. http://medicine.missouri.edu/ortho/Bal/hip-replacement-basics.html

US heathcare is a cartel, IMHO. State law (MN) requires all hospitals to be "non-profit" which makes it worse. Obamacare continues all those problems and adds a plethora more. Everything we do in terms of public policy and healthcare policy, it seems to me, is designed to make things more expensive.

Our system is flawed, and the Soviet-style, central-planned model is worse.

I'm sure that still did not answer your question. But if you look into the Spanish system, I'm sure you will find they use their single payer clout to drive the cost down to only cover the variable cost to build the hip, like Canadians buying US medicines. That doesn't work for the largest economy in the world because if someone did not pay for the fixed costs and development costs, the products never would be developed.

Agreed that pre-Obamcare we were quite far from free market, but when we talk about free market people hear "If you don't have enough money you will be allowed to die in the street" etc.

With what we have had in the last few entries still does not give me (us?) the sort of concise, to the point answer that one must have in order to be persuasive in these sorts of conversations.

For example, at present I have:

a) greater competition through a unified national market, instead of 50 separate marketsb) greater transparency as to what policies do and do not cover; analogous to the list of contents on a package of food; c) greater freedom of choice as to what coverage you buy;d) transparency as to prices so as to enable competition via price.

a) greater competition through a unified national market, instead of 50 separate marketsb) greater transparency as to what policies do and do not cover; analogous to the list of contents on a package of food; c) greater freedom of choice as to what coverage you buy;d) transparency as to prices so as to enable competition via price.*****

I would be curious to also find out if the hospitals that encouraged admission to be able to bill also encourages rapid as possible discharge to avoid accumulating costs vs. the fixed reimbursements. The latter happens all the time not always unethical or wrong but the other end of the same coin I guess:

******Suits: How a Hospital Chain Schemed to Boost Profits

'NYT' looks at lawsuits against Health Management Associates

By Arden Dier, Newser Staff

Posted Jan 24, 2014 9:41 AM CST

(Newser) – The New York Times today takes a look at whistle-blower lawsuits claiming for-profit hospital chain Health Management Associates employed a strategy to up admission—whether or not patients needed care—in order to boost Medicare and Medicaid payments. The paper shares one tactic, in which ER scorecards were posted daily, showing doctors who met an admission target in green. Doctors who were close to the figure were in yellow, and failing doctors in red. That target? Admitting at least half of patients over 65 who visited the emergency room. In another case, a baby was admitted with a "fever" despite a normal temperature of 98.7 degrees.

When the CEO of an HMA-owned North Carolina hospital reported that his doctors wouldn't go along with the revenue-boosting policies, former HMA chief exec Gary Newsome—who made $22 million in three years—allegedly replied, "Do it anyway." Threats and financial incentives were also allegedly used, while execs who questioned the policies were often fired and reports on admission rates were burned, the Times adds. So far eight whistle-blower lawsuits have been filed against HMA in six states; last month, the Justice Department joined in, but one expert says typical penalties number in the 8-figure-range—pennies compared to the profits. She predicts it would take a settlement of at least $500 million to make an impact. To wit, the Times reports that when HMA revealed the DOJ was stepping into the lawsuits, its stock hardly moved.*****

Don’t worry. I have it on good authority from a Nigerian prince and a friend who lost his wallet in Vladivostok that these guys were totally on the level:

U.S. intelligence agencies last week urged the Obama administration to check its new healthcare network for malicious software after learning that developers linked to the Belarus government helped produce the website, raising fresh concerns that private data posted by millions of Americans will be compromised.

The intelligence agencies notified the Department of Health and Human Services, the agency in charge of the Healthcare.gov network, about their concerns last week. Specifically, officials warned that programmers in Belarus, a former Soviet republic closely allied with Russia, were suspected of inserting malicious code that could be used for cyber attacks, according to U.S. officials familiar with the concerns.

The software links the millions of Americans who signed up for Obamacare to the federal government and more than 300 medical institutions and healthcare providers.

“The U.S. Affordable Care Act software was written in part in Belarus by software developers under state control, and that makes the software a potential target for cyber attacks,” one official said.

We’ve been hearing all along that the architecture of the Healthcare.gov website is particularly susceptible to hacker penetration. David Kennedy, a former Marine Corps cyberwarfare expert turned Internet security consultant, has warned since October that the system leaves critical identity information exposed. That got worse rather than better after the operational fixes made in November, and HHS doesn’t even have systems in place to detect such intrusions.

Small wonder why the Obama administration didn’t want to brief Congress on security issues in December. These security gaps were presumed to be the product of incompetent programming and management. Until now, we didn’t realize that the subcontracts for programming went in part to a firm connected with a hostile regime. Belarus has remained a satellite to Moscow with a dictator in charge ever since the breakup of the Soviet Union, Alexander Lukashenko, and the regime is decidedly unfriendly to the West. Currently, the US doesn’t even recognize the legitimacy of Lukashenko’s government after his rigged 2010 election.

How did this happen? Normally, we’d pay good money to keep hostile regimes from penetrating our government operations. In this case, it looks as though we paid them to do it. Great job, HHS!

But it’s not all bad. If you think your identity information has been hijacked, just call the ObamaCare hotline. Be sure to ask for Peggy.

There are 7.8 million Americans working part-time who want full-time work, including a fry cook whose restaurant cut his hours to avoid Affordable Care Act mandates and confronted President Obama in an online Google GOOG -0.11% Q&A last week: "We can't survive. It's not a living." Mr. Obama changed the subject to raising the minimum wage. But he can't dodge reality forever as the evidence piles up that ObamaCare is harming the labor market.

On Tuesday no less than the Congressional Budget Office reported that the health law is causing Americans to work less or not at all, in a remarkable intellectual turnabout for the budget shop that Democrats cited repeatedly when selling ObamaCare. Now CBO—full of liberal-leaning economists—says the economy will lose the equivalent of two million full-time workers by 2017 and 2.5 million over the next decade, a threefold increase over its prior estimate.

CBO's analysis is rooted in ObamaCare's complex design that includes new subsidies, taxes and mandates. For low-wage, lower-skilled or discouraged workers in particular, ObamaCare offers incentives that can force them to trade jobs for entitlement benefits.

CBO's conclusion is that ObamaCare will encourage people to supply less labor by deciding not to take a job or by working fewer hours. The law's insurance subsidies are gradually taken away as income rises, "creating an implicit tax on additional earnings," the CBO observes. These effective marginal tax rates reduce the rewards for work—whether it be overtime, accepting a promotion, or training in the hope of higher future earnings. CBO doesn't note, though we will, that simply extending "free" coverage skews job search decisions by offering an in-kind bonus for unemployment.

CBO's job-loss prediction is all the more remarkable because it doesn't include the impact of ObamaCare's employer mandate, which requires businesses with 50 or more full-time employees to offer insurance or pay a $2,000 penalty for each worker beyond 30 employees. CBO more or less punts on the issue because the White House delayed the mandate for a year and the changes would be hard to model. But this means CBO is probably still underestimating job losses because common sense says that labor mandates raise hiring costs and induce businesses to hire less, or pay lower wages, or slash hours, or all three.

Too bad this reality isn't permeating the liberal force field of thinking only positive thoughts. "Claims that the Affordable Care Act hurts jobs are simply belied by the facts in the CBO report," the White House declared Tuesday. By "facts," the White House seems to mean that the report is positive because "individuals will be empowered to make choices about their own lives and livelihoods" and "have the opportunity to pursue their dreams." There you have it: the new American dream of not working.

All of this is one more contradiction of the arguments that were used to sell ObamaCare. The law would reduce health-care costs and shrink the deficit, you could keep your health plan and your doctor, and businesses could hire more workers and be more competitive. All of this is turning out to be false, and now we learn that the law is a job destroyer that is removing rungs from the ladder of upward economic mobility.

WSJ interview with Casey Mulligan, University of Chicago, National Bureau of Economic Research, the economist who predicted ACA would contract the labor market by 3%."Taking away benefits has the same effect as a direct tax, so lower-income workers are discouraged from climbing the income ladder by working harder, logging extra hours, taking a promotion or investing in their future earnings through job training or education."

The Economist Who Exposed ObamaCareThe Chicago professor examined the law's incentives for the poor not to get a job or work harder, and this week Beltway budgeteers agreed.

In September, two weeks before the Affordable Care Act was due to launch, President Obama declared that "there's no serious evidence that the law . . . is holding back economic growth." As for repealing ObamaCare, he added, "That's not an agenda for economic growth. You're not going to meet an economist who says that that's a number-one priority in terms of boosting growth and jobs in this country—at least not a serious economist."

In a way, Mr. Obama had a point: "Never met him," says economist Casey Mulligan. If the unfamiliarity is mutual, the confusion is all presidential. Mr. Mulligan studies how government choices influence the incentives and rewards for work—and many more people may recognize the University of Chicago professor as a serious economist after this week. That's because, more than anyone, Mr. Mulligan is responsible for the still-raging furor over the Congressional Budget Office's conclusion that ObamaCare will, in fact, harm growth and jobs.Enlarge Image

Rarely are political tempers so raw over an 11-page appendix to a dense budget projection for the next decade. But then the CBO—Congress's official fiscal scorekeeper, widely revered by Democrats and Republicans alike as the gold standard of economic analysis—reported that by 2024 the equivalent of 2.5 million Americans who were otherwise willing and able to work before ObamaCare will work less or not at all as a result of ObamaCare.

As the CBO admits, that's a "substantially larger" and "considerably higher" subtraction to the labor force than the mere 800,000 the budget office estimated in 2010. The overall level of labor will fall by 1.5% to 2% over the decade, the CBO figures.

Mr. Mulligan's empirical research puts the best estimate of the contraction at 3%. The CBO still has some of the economics wrong, he said in a phone interview Thursday, "but, boy, it's a lot better to be off by a factor of two than a factor of six."

The CBO's intellectual conversion is all the more notable for accepting Mr. Mulligan's premise, which is that what economists call "implicit marginal tax rates" in ObamaCare make work less financially valuable for lower-income Americans. Because the insurance subsidies are tied to income and phase out as cash wages rise, some people will have the incentive to remain poorer in order to continue capturing higher benefits. Another way of putting it is that taking away benefits has the same effect as a direct tax, so lower-income workers are discouraged from climbing the income ladder by working harder, logging extra hours, taking a promotion or investing in their future earnings through job training or education.

The CBO works in mysterious ways, but its commentary and a footnote suggest that two National Bureau of Economic Research papers Mr. Mulligan published last August were "roughly" the most important drivers of this revision to its model. In short, the CBO has pulled this economist's arguments and analysis from the fringes to center of the health-care debate.

For his part, Mr. Mulligan declines to take too much credit. "I'm not an expert in that town, Washington," he says, "but I showed them my work and I know they listened, carefully."

At a February 2013 hearing he pointed out several discrepancies between the CBO's marginal-tax-rate work and its health-care work, and, he says, "That couldn't persist forever. There would have to be a time where they would reconcile those two approaches somehow." More to the point, "I knew eventually it would be acknowledged that when you pay people for being low income you are going to have more low-income people."

Mr. Mulligan thinks the CBO deserves particular credit for learning and then revising the old 800,000 number, not least because so many liberals cited it to dispute the claims of ObamaCare's critics. The new finding might have prompted a debate about the marginal tax rates confronting the poor, but—well, it didn't.

Instead, liberals have turned to claiming that ObamaCare's missing workers will be a gift to society. Since employers aren't cutting jobs per se through layoffs or hourly take-backs, people are merely choosing rationally to supply less labor. Thanks to ObamaCare, we're told, Americans can finally quit the salt mines and blacking factories and retire early, or spend more time with the children, or become artists.

Mr. Mulligan reserves particular scorn for the economists making this "eliminated from the drudgery of labor market" argument, which he views as a form of trahison des clercs. "I don't know what their intentions are," he says, choosing his words carefully, "but it looks like they're trying to leverage the lack of economic education in their audience by making these sorts of points."

A job, Mr. Mulligan explains, "is a transaction between buyers and sellers. When a transaction doesn't happen, it doesn't happen. We know that it doesn't matter on which side of the market you put the disincentives, the results are the same. . . . In this case you're putting an implicit tax on work for households, and employers aren't willing to compensate the households enough so they'll still work." Jobs can be destroyed by sellers (workers) as much as buyers (businesses).

He adds: "I can understand something like cigarettes and people believe that there's too much smoking, so we put a tax on cigarettes, so people smoke less, and we say that's a good thing. OK. But are we saying we were working too much before? Is that the new argument? I mean make up your mind. We've been complaining for six years now that there's not enough work being done. . . . Even before the recession there was too little work in the economy. Now all of a sudden we wake up and say we're glad that people are working less? We're pursuing our dreams?"

The larger betrayal, Mr. Mulligan argues, is that the same economists now praising the great shrinking workforce used to claim that ObamaCare would expand the labor market.

He points to a 2011 letter organized by Harvard's David Cutler and the University of Chicago's Harold Pollack, signed by dozens of left-leaning economists including Nobel laureates, stating "our strong conclusion" that ObamaCare will strengthen the economy and create 250,000 to 400,000 jobs annually. (Mr. Cutler has since qualified and walked back some of his claims.)

"Why didn't they say, no, we didn't mean the labor market's going to get bigger. We mean it's going to get smaller in a good way," Mr. Mulligan wonders. "I'm unhappy with that, to be honest, as an American, as an economist. Those kind of conclusions are tarnishing the field of economics, which is a great, maybe the greatest, field. They're sure not making it look good by doing stuff like that."

Mr. Mulligan's investigation into the Affordable Care Act builds on his earlier work studying the 2009 Recovery and Reinvestment Act, aka the stimulus.

The Keynesian economists who dominate Mr. Obama's Washington are preoccupied by demand, and their explanation for persistently high post-recession unemployment is weak demand for goods and thus demand for labor. Mr. Mulligan, by contrast, studies the supply of labor and attributes the state of the economy in large part to the expansion of the entitlement and welfare state, such as the surge in food stamps, unemployment benefits, Medicaid and other safety-net programs. As these benefits were enriched and extended to more people by the stimulus, he argues in his 2012 book "The Redistribution Recession," they were responsible for about half the drop in work hours since 2007, and possibly more.

The nearby chart tracks marginal tax rates over time for nonelderly household heads and spouses with median earnings. This index is a population-weighted average over various ages, jobs, employment decisions like full-time versus part-time. Basically, the chart shows the extra taxes paid and government benefits foregone as a result of earning an extra dollar of income.

The stimulus caused a spike in marginal rates, but at least it was temporary. ObamaCare will bring them permanently into the 47% range, or seven percentage points higher than in early 2007. Mr. Mulligan says the main response to his calculations is that people "didn't realize the cumulative effect of these things together as a package to discourage work."

Mr. Mulligan is uncomfortable speculating about whether the benefits of this shift outweigh the costs. Perhaps the public was willing to trade market efficiency for more income security after the 2008 crisis. "As an economist I can't argue with that," he says. "The thing that I argue with is the denial that there is a trade-off. I argue with the denial that if you pay unemployed people you're going to get more unemployed people. There are consequences of that. That doesn't mean the consequences aren't worth paying. But you can't deny the consequences for the labor market."

One major risk is slower economic growth over time as people leave the workforce and contribute less to national prosperity. Another is that social programs with high marginal rates end up perpetuating the problems they're supposed to be alleviating.

So amid the current wave of liberal ObamaCare denial about these realities, how did Mr. Mulligan end up conducting such "unconventional" research?

"Unconventional?" he asks with more than a little disbelief. "It's not unconventional at all. The critique I get is that it's not complicated enough."

Well, then how come the CBO's adoption of his insights is causing such a ruckus?

"I would phrase the question a little differently," Mr. Mulligan responds, "which is: Why didn't conventional economic analysis make its way to Washington? Why was I the only delivery boy? Why wasn't there a laundry list?" The charitable explanation, he says, is that there was "a general lack of awareness" and economists simply didn't realize everything that government was doing to undermine incentives for work. "You have to dig into it and see it," he explains. "The Affordable Care Act's not going to come and shake you out of your bed and say, 'Look what's in me.' "

Judging by their reaction to the CBO report, the less charitable explanation is that liberals would have preferred that the public never found out.

Is this what Nancy Pelosi meant by have to pass it to find out what's in it? Why wasn't an honest and dynamic assessment of its impact a requirement for passage?

From the Congressional Budget Office: http://www.cbo.gov/sites/default/files/cbofiles/attachments/45010-Outlook2014.pdf

CBO estimates that the ACA [Affordable Care Act] will reduce the total number of hours worked, on net, by about 1.5 percent to 2.0 percent during the period from 2017 to 2024, almost entirely because workers will choose to supply less labor—given the new taxes and other incentives they will face and the financial benefits some will receive.

Greg Mankiw, Harvard: http://gregmankiw.blogspot.com/2014/02/sentence-of-day.htmlImplicit in this estimate are elasticities that measure how much people respond to incentives. My sense is that CBO is typically conservative when it come to gauging these incentives effects. So I would take their estimate of the impact on hours worked as a lower bound. The actual figure (of jobs and work lost) may be higher (than 2.5 million).

Perfect leftism. We will achieve prosperity by having fewer workers work shorter hours at a lower wage rate.

Who knew this would happen (in 2009)?

http://www.nytimes.com/2009/11/01/business/economy/01view.html?_r=0The signature domestic issue in President Obama’s first year in office — health care reform — is shaping up to be the antithesis of President Reagan’s supply-side economics. The starting point for Ronald Reagan was the idea that people respond to incentives. ... President Obama has said he wants to raise marginal tax rates on high-income taxpayers. Yet under his policies, the largest increases in marginal tax rates may well apply not to the rich but to millions of middle-class families. These increases would not show up explicitly in the tax code but, rather, implicitly as part of health care reform.

One might hope that such a large climb in marginal rates is a bug in the Senate Finance bill (2009, which became the ACA), one that could be fixed before the legislation became law. But there is no simple fix. Higher marginal tax rates are an integral part of the Obama health plan.

Health reformers start with the problem that some people are expensive to insure, because of pre-existing health conditions. Their solution is to require insurers to sell insurance to everyone (a policy called guaranteed issue) at the same price (called community rating).

This solution, however, causes another problem. For healthy people, insurance is now a bad bet. A person without significant medical needs has an incentive to wait — to buy insurance later if and when he gets sick, a decision that raises the cost of insurance for everyone else. This problem, according to the reformers, calls for another solution: a mandate requiring people to buy health insurance.

But this mandate leads to yet another problem. Requiring an expensive purchase like health insurance can be onerous for low-income families. So the health reformers offer subsidies.

Which brings us back to marginal tax rates. If large health insurance subsidies were offered to all Americans, regardless of income, the program’s cost would be exorbitant, requiring substantial increases in explicit taxes. So, instead, the subsidies are phased out as income rises. As a result, we get implicit marginal rates like those in the Senate Finance bill [ACA]. - Greg Mankiw, NY Times, Oct 31, 2009

Remember that ObamaCare insurance bailout? Well, the first stats are in forone insurer and it's not pretty. The American Enterprise Institute's ScottGottlieb writes(http://www.forbes.com/sites/scottgottlieb/2014/02/06/obamacare-bailout-for-one-insurer-450-million-in-2014/),"Humana announced that it expects to tap the three risk adjustment mechanismsin ObamaCare for between $250 and $450 million in 2014. This amounts to about25 percent of the insurer's expected exchange revenue." That's also just oneinsurer! More will undoubtedly follow. Not only that, but Humana enrolled202,000 people via the ObamaCare exchanges as of Jan. 31, and some 82% of themwere eligible for subsidies. The price of Hope 'n' Change™ just keeps goingup.

Humana is extraordinarily brutal health insurer. It is always about the bottom line for them. They are moving into Jersey I am told in a big way by offering the best deals. Sounds good now but once they gain market share they will start turning the screws not only on providers but patients too.

The Obama propaganda machine is in fifth gear. Even Hitler’s Minister of Propaganda didn’t try to sell unemployment to the Germans. They used it to sell …. war, but this is Goebbels to the next level. And it’s voluntary state media — this is The Washington Post spreading this manure.

I don’t know who or what we are, but this is not America. It’s war on every basic and good fundamental value America ever held dear.

“Just when you think the Washington Post has hit rock bottom, they sink deeper into the tar-pit” By Director Blue [2]

To paraphrase Jim Geraghty [3], in a nation of 320 million people, I’m sure you can find someonewho’s happy with Obamacare. [4]And guess what? The execrable Washington Post and someone named “Sandhya Somashekhar” [5] – which I’m pretty sure is pronounced “Gesundheit!” — found someone delighted that they can quit their job. You know, to “escape job lock”, which is the new term for Obamacare-induced unemployment.

And guess what? The execrable Washington Postand someone named “Sandhya Somashekhar” [5] – which I’m pretty sure is pronounced “Gesundheit!” — found someone delighted that they can quit their job. You know, to “escape job lock”, which is the new term for Obamacare-induced unemployment.

Count Polly Lower among those who quit their jobs because of the health-care law… It happened in September, when her boss abruptly changed her job description. She went from doing payroll, which she liked, to working on her boss’s schedule, which she loathed…

Hold up: Polly had to work on her boss’s schedule? Oh, the humanity!

At another time, she might have had to grit her teeth and accept the new position because she needed the health benefits… But with the health-care law soon to take effect, she simply resigned — and hasn’t looked back.

“It was wonderful. It was very freeing,” said Lower, 56, of Bourbon, Ind…

Yes, isn’t being jobless an aspirational goal for everyone? You know, so they can pursue their goals, like writing cowboy poetry or weaving risque macrame.

…[Lower] is now babysitting her 5-year-old granddaughter full time. With the help of federal subsidies that kicked in Jan. 1, she is paying less than $500 a month for health coverage for herself and her husband.

So let’s state this more clearly: thanks to Obamacare, Lower has now joined the roughly 100 million Americans collecting an average of $9,000 each from more than 80 means-tested welfare programs [6].

The Washington Post found … Lower through Families USA, a health advocacy group that supports the health-care law and maintains a database of people who have benefited from it.

[7]And just who is Families USA? They’re an SEIU front group [7] that has been pushing for socialized medicine for years [8].

In short, the Washington Post is doing its level best to protect Democrats as we head into the 2014 midterm elections even as millions lose their jobs and their health care; and as many as 100 million more may be similarly impacted in 2015, unless the Imperial President rewrites the Obamacare law again through executive edict.

And where does “Sandhya Somashekhar” and the Washington Post find their loathsome propaganda? Why a hardcore, militant labor union aligned with the Marxist-Leninist movement [9], of course!

Our goal as socialists is to abolish private ownership of the means of production. Our immediate task is to limit the capitalist class’s prerogatives in the workplace…In the short run we must at least minimize the degree of exploitation of workers by capitalists. We can accomplish this by promoting full employment policies, passing local living wage laws, but most of all by increasing the union movement’s power…

…the real CBO story should be: “That awkward moment when everyone realizes Obamacare was a huge mistake.” The same CBO report projects that by 2024 the number of non-elderly uninsured will be — drum roll, please — 31 million Americans.

And that’s why all of this talk of Democrats as the Job-Lock Liberators is pathetic and hilarious at the same time. Virtually every promise has been broken, every prediction falsified. And now, at a time when millions want work that doesn’t exist, Democrats are claiming victory by trimming the amount of work actually being done.

Hopefully voters will look for ways to liberate these Democrats from the curse of job-lock come November.

The title of the WaPo secretion is “They quit their jobs, thanks to health-care law.”

I don’t think that headline means what they think it means.

Logged

"You have enemies? Good. That means that you have stood up for something, sometime in your life." - Winston Churchill.

Humana is extraordinarily brutal health insurer. It is always about the bottom line for them. They are moving into Jersey I am told in a big way by offering the best deals. Sounds good now but once they gain market share they will start turning the screws not only on providers but patients too.

If you think Humana is brutal, wait until the feds really run healthcare.

"If you think Humana is brutal, wait until the feds really run healthcare."

In my experience this is not true.

I worked for Humana. On one hand they paid the bills. On the other, they never let anyone know otherwise. It was literally a battle between the patients and the insurer over coverage. Every day and all day. One of Humana's medical directors said point blank, they [patients] are the enemy. It is us against them. Another Humana administrator said with a smile about someone who would not accept to go into hospice, "look your dead, your dead, your dead".

The Feds are not as brutal (at least yet).

But, I choose a free marketplace. I don't wish for a Federal politburo controlling the entire healthcare industry.

That said I am a squirt. My thoughts are worthless in the real world as they are against anyone with political or financial connections or anyone with real world power and know how.